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Magic Jump Rentals / City Birthday Party 17ta Qwkra — (7EM ojWv DESERT — MEMORANDUM TO: Chris Escobedo, Community Resources Director FROM: Jaime Torres, Management Assistant DATE: April 19, 2017 RE: Bounce House, Euro Bungee, and Rock Climbing Wall for City Picnic Attached for your signature is THE SHORT FORM SERVICES AGREEMENT for bounce house, euro bungee, and rock climbing wall for the picnic and birthday celebration on Saturday, April 29, 2017. Please sign the attached agreement(s) and return to the City Clerk for processing and distribution. Requesting department shall check and attach the items below as appropriate: X Contract payments will be charged to account number: 101-3003-60149 X Amount of Agreement, Amendment, Change Order, etc.: $2,045.00 NA A Conflict of Interest Form 700 Statement of Economic Interests from Consultant(s) is attached with no reportable interests in LQ or reportable interests NA A Conflict of Interest Form 700 Statement of Economic Interests is not required because this Consultant does not meet the definition in FPPC regulation 18701(2). Authority" execute this agreement is based upon: N/A Approved by the City Council on N/A City Manager's signature authority provided under Resolution No. 2015-045 for budgeted expenditures of $50,000 or less. This expenditure is $9,900 and authorized by contract approved by Council. NA Initial to certify that 3 written informal bids or proposals were received and considered in selection The following required documents are attached to the agreement: X Insurance certificates as required by the agreement (approved by Risk Manager on ) NA Performance bonds as required by the agreement (originals) X City of La Quinta Business License number LIC-764847 NA Purchase Order number 1. organiz( at 78-4 supplier ("Vendo "Parties' 2. 3. and t(vQ�� - - GEM aftheDESERT — CITY OF LA QUINTA SHORT -FORM SERVICES AGREEMENT ($25,000 OR LESS) IRTIES AND DATE. This Agreement is made and entered into this fifth day of April, 2017, e Date") by and between the City of Lo Quinta, a Municipal Corporation and Charter City i under the Constitution and laws of the State of California with its principal place of business 5 Calle Tampico, La Quinta, CA ("City") and Magic Jump Rentals, an event carnival ride with its principal place of business at 765 S. Lugo Avenue, Son Bernardino, CA 92408 I. City and Vendor are sometimes individually referred to as "Party" and collectively as in this Agreement. AND CONDITIONS. The Parties shall comply with the terms and conditions in the attached t"A„ AND SCHEDULE OF SERVICES. Vendor shall provide to City the services pursuant to the dates) (s) described in accordance with the schedule set forth in Exhibit "B". 4. T Rho. The term of this Agreement shall be from Saturday, April 29, 9:00 a.m. to I:oo p.m., unless earlier terminated as set forth in the attached Terms and Conditions. This Agreement may not extend t eyond a period of five (5) years, unless under the City's Fiscal Policies and Procedures this AgreemE nt is exempt from the five (5) year limitation. 5. COMPENSATION. Vendor shall receive compensation for services rendered under this Agreement at the r tes and schedule set forth in the attached Exhibit "C" but in no event shall Vendor's compen ation exceed two -thousand and forty-five dollars and no cents ($2,045.00) per fiscal year (July 1 tc June 30) without written amendment. 6. FORCE MAJEURE. The time period specified for performance of the services rendered pursuant to this Agreement shall be extended because of any delays due to unforeseeable causes beyond the control and without the fault or negligence of Vendor including, but not restricted to, acts of Gad or of the public enemy, fires, earthquakes, floods, epidemic, quarantine restrictions, riots, strikes, freight embargoes, acts of any governmental agency other than City, and unusually severe weather, if Vendor shall within ten (10) days of the commencement of such delay notify the City in writing of the causes of the delay. The City shall ascertain the facts and the extent of delay, and extend the time for performitig the Services for the period of the forced delay when and if in their judgment such delay is justified, and the City's determination shall be final and conclusive upon the parties to this Agreement. Extensions to time periods for performance of services, which are determined by the City to be justified pursuant to this Section, shall not entitle the Vendor to additional compensation unless City expressly agrees to an increase in writing. I 7. INSURANCE. In accordance with Section 4 of Exhibit "A", Vendor shall, at its expense, procure and maintain for the duration of the Agreement such insurance policies as checked below and provide proof of such insurance policies to the City. Vender shall obtain policy endorsements on Commercial General Liability Insurance that name Additional Insureds as follows: The City of Lo Quinta, its officers officials, employees and agents. Comme vial General Liability Insurance: $1,000,000 per occurrence/$2,000,000 aggregate OR ❑ $2,000,000 per occurrencel$4,000,000 aggregate. ❑ Additional Insured Endorsement naming City of La Quinta (above) Automo ile Liability: 0 $1,000,000 combined single limit for bodily injury and property damage. Workers Compensation: Statutory Limits 1 Employer's Liability $1,000,000 per accident or disease. ❑ Workers' Compensation Endorsement with Waiver of Subrogation Professic not Liability (Errors and Omissions): ❑ Errors and Omissions liability insurance with a limit of not less than $1,000,000 per claim. 114 WITNESS WHEREOF, each of the Parties has caused this Agreement to be executed on the day and year first above written. CITY OF A QUINTA t. �u YY--,. ik Digitally signed by FrankJ. Spevacek VENDOR NAME DN:cn=FrankJ.Spevacek,o=City of La Quinta, ou=City Manager, ema i I=fspevacek@la-q uinta.org, c=US By: Date: 2017.04.25 17:16:26-07'00' By: {\' QI a r` A Di 1A STAFF NAME OWNER/OFFICER NAME �Y STAFF TITLE OWNERIOFFICER TITLE Requirel for over $5,000: By: By: OWNER/OFFICER NAME DEPARTMENT DIRECTORIMANAGER OWNER/OFFICER TITLE APPROVED AS TO FORM: WILLIAM H. IHRKE, City Attorney City of Lo Quinta, California i. ATTEST: SUSAN MAYSELS, City Clerk City of La Quinta, California EXHIBIT "A" TERMS AND CONDITIONS 1. ompensation. Vendor shall be paid on a time and oterials or lump sum basis, as may be set forth J in E hibit "C", within 30 days of completion of the War i and apprcvoI by the City. 2. all c stat City, perr loca all ( and War 3. c War prof man ordii proc 4. main this Insu the prop Servl cove amp the occu Liabi darn and acci( least Num with whit/ liabill the [ do b, proc( have )mpliance with Low. Vendor shall comply with aplicable laws and regulations of the federal, and local government. Vendor shall assist the as requested, in obtaining and maintaining all its required of Vendor by Federal, State and regulatory agencies. Vendor is responsible for ]sts of clean up and/or removal of hazardous oxic substances spilled as a result of his or her ndard of Care. The Vendor shall perform the in accordance with generally accepted sionai practices and principles and in a ar consistent with the level of care and skill rily exercised by members of the profession dng under similar conditions. Insurance. The Vendor shall take out and Lain, during the performance of all work under Agreement: A. Commercial General Liability once in the amounts specified in Section 6 of greement for bodily injury, personal injury and !rty damage, at least as broad as Insurance :es Office Commercial General Liability age (Occurrence Form CG 0001), and if no int is selected in Section 6 of the Agreement, amounts shall be $1,000,000 per rencet$2,000,000 aggregate, B. Automobile ty Insurance for bodily injury and property ge including coverage for owned, non -owned hired vehicles, of at least $1,000,000 per ent for bodily injury and property damage, at as broad as Insurance Services Office Form rer CA 0001 (ed. 6/92) covering automobile :y, Code 1 (any auto); C. Workers' ensotion in compliance with applicable :ory requirements and Employer's Liability age of at least $1,000,000 per accident or ie. Vendor shall also submit to City a waiver of gation endorsement in favor of city, and D. isional Liability (Errors and Omissions) age, if checked in section 6 of the Agreement, i limit not less than $1,000,000 per claim and shall be endorsed to include contractual y. Insurance carriers shall be authorized by epartment of Insurance, State of California, to siness in California and maintain an agent for ss within the state. Such insurance carrier shall not less than an "A'; "Class VII" according to 01737.2 A-1 the latest Best Key Rating unless otherwise approved by the City. S. Indemnification. The Vendor shall indemnify and hold harmless the City, its Council, members of the Council, agents and employees of the City, against any and all claims, liabilities, expenses or damages, including responsible attorneys' fees, for injury or death of any person, or damage to property, or interference with use of property, or any claim of the Vendor or subcontractor for wages or benefits which arise in connection with the performance of this Agreement, except to the extent caused or resulting from the active negligence or willful misconduct of the City, its Council, members of the Council, agents and employees of the City. The foregoing indemnity includes, but is not limited to, the cost of prosecuting or defending such action with legal counsel acceptable to the City and the City's attorneys' fees incurred in such an action. 6. Laws and Venue. This Agreement shall be interpreted in accordance with the laws of the State of California. If any action is brought to interpret or enforce any term of this Agreement, the action shall be brought in a state or federal court situated in the County of Riverside, State of California. 7. Termination. The City may terminate the services procured under this Agreement by giving 10 calendar days written notice to Vendor. In such event, the City shall be immediately given title and possession to any original field notes, drawings and specifications, written reports and other documents produced or developed for the services. The City shall pay Vendor the reasonable value of services completed prior to termination. The City shall not be liable for any costs other than the charges or portions thereof which are specified herein. Vendor shall not be entitled to payment for unperformed services, and shall not be entitled to damages or compensation for termination of work. Vendor may terminate its obligation to provide services under this Agreement upon 30 calendar days' written notice to the City only in the event of City's failure to perform in accordance with the terms of this Agreement through no fault of Vendor. 8. Agreement Terms. Nothing herein shall be construed to give any rights or benefits to anyone other than the City and the Vendor. The unenforceability, invalidity or illegality of any provision(s) of this Agreement shall not render the other provisions unenforceable, invalid or illegal. Notice may be given or delivered by depositing the some in any United States Post Office, certified maid, to trar inte con em em receipt requested, postage prepaid, addressed parties to the addresses set forth in the ment. Vendor shall not assign, sublet, or er this Agreement or any rights under or st in this Agreement without the written nt of the City, which may be withheld for any i. Vendor is retained as an independent actor and is not on employee of the City. No yee or agent of Vendor shall become on yee of the City. The individuals signing this 101737.2 A-2 Agreement represent that they have the authority to sign ❑n behalf of the parties and bind the parties to this Agreement. This is an integrated Agreement representing the entire understanding of the parties as to those matters contained herein, and supersedes and cancels any prior oral or written understanding or representations with respect to matters covered hereunder. This Agreement may not be modified or uttered except in writing signed by bath parties hereto. EXHIBIT "B" SCOPE AND SCHEDULE OF SERVICES view attached invoice #6205 dated 03/29/2017, a-1 Magic Jump Rentals Riverside, LLC. 765 S. Lugo Ave. It' San Bernardino, CA 92408 Phone (951)425-5558 Pax (818)848.0353 Email: into- rivCQmagicjumprentais.com Custotn$r Information Customer ID: 2284 Lq Events. 760-777 89 Igevents la-quinta.org Order it s Description 25' Rock Wall Lite Sports Combo EZ S its Combo Waterslide (1) Euro Bun gee 4000 Ger erator a Ge erator Gas Refill?: No Da age Waiver: No Order NIA Event Location Civic Center 78495 Calle Tampico La Quinta, CA 92253 Special In tructions Rock wall i $600 for minimum of 4 Euro Bung a $1100 for 4 hours Event start at gam-1 pm Will mail a heck for $205, outstanding balance after deposit $1840.00 Carder #6205 Prepared On Mar 29, 2017 Rental Date & Time Saturday Apr 29, 2017 7.00am to Saturday Apr 29, 2017 1:00pm ESfrmated Dick -Up: 1 pm 1 600.00 600.00 1 120.00 120.00 1 1,100.00 1,100.00 1 75.00 75.00 Sub -Total: $1,895.00 Delivery Charge: $150.00 Additional Fees: $0.00 Tax (8.75%): $0.00 Order Total: $2,045.00 Payments Received: $0.00 Balance Due: $2,045.00 EXHIBIT "C" COMPENSATION FOR SERVICES for Services to be billed on a time and materials basis unless otherwise set forth below. All *ork shall be billed based on the following Rate Schedule: Please see the invoice attached ins hedule B. C-a C� DATE (MM/DD/YYYY) ACC]R" CERTIFICATE OF LIABILITY INSURANCE 04/04/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Sam Murad an INSURED Liberty United Insurance Services, Inc. 704 S Victory Blvd, Suite 204 Burbank, CA 91502 License #: OF89841 Magic Jump Rentals Riverside, LLC 765 Lugo Ave San Bernardino, CA 92408 NAME: y PHONE No Ext : (818)761-8888 FAX No): (888)265-6889 E-MAIL nnnwFac• Sam@libertvunitedinsurance.com INSURER E : INSURER F : Ct7VFRAGFS CFRTIFICATF NIIMRFR, nnnnnnnn-n RFVIRInN NIIMRFR- 1n7 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL D SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y N SRPGAP-101-0716 02/26/2017 02/26/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE F7x OCCUR A Al To INTEI PREM SES Ea occurrence) ccurence $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY jE LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N PER OTH- STATUTE I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICERIMEMBEREXCLUDED7 F7 N/A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder is an Additional Insured Scheduled activities exclusion endorsement applies: Bubble Soccer, Mechanical Bucking Devices: including Multi Ride Attachments, Zip Line, Trampolines, & Permanent Rock Wall Structure. CFRTIFICATF HoI_nFR CANCFI_I_ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of La Quinta THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 78-495 Calle Tampico ACCORDANCE WITH THE POLICY PROVISIONS. La Quinta, CA 92253 AUTHORIZED REPRESENTATIVE s (SMS) © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by SMS on April 04, 2017 at 11:27AM COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION Policy Number: SRPGAP-101-0716 Insured: Magic Jump Rentals Riverside, LLC This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) City of La Quinta 78-495 Calle Tampico La Quinta, CA 92253 Information required to complete this Schedule, if not shown above will be shown in the Declarations. Section II - WHO IS AN INSURED is amended to include as an insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury' caused, in whole or in part, by your acts or omissions of the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 CUSTOMER NUMBER: 918317 MARC ST. JULIEN 14847 MAGNOLIA BLVD STE 204 SHERMAN OAKS, CA 91403 CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253-2839 RUN DATE: 04-18-17 Certificate Copy Cl CW A02 10 11 CERTIFICATE OF INSURANCE This certificate is issued for informational purposes only. It certifies that the policies listed in this document have been issued to the Named Insured. It does not grant any rights to any party nor can it be used, in any way, to modify coverage provided by such policies. Alteration of this certificate does not change the terms, exclusions or conditions of such policies. Coverage is subject to the provisions of the policies, including any exclusions or conditions, regard- less of the provisions of any other contract, such as between the certificate holder and the Named Insured. The limits shown below are the limits provided at the policy inception. Subsequent paid claims may reduce these limits. Certificate Holder: CITY OF LA QUINTA 78495 CALLE TAMPICO LA QUINTA, CA 92253-2839 Named Insured: MAGIC JUMP RENTALS 765 S LUGO AVE SAN BERNARDINO CA 92408-2235 Automobile Liability Insurer Name: Allstate Insurance Company To icy Number: 648442254 1 -Any Auto 2 - Owned Autos Only 3 - Owned Priv. Pass. Autos Only 4 - Owned Autos Other Than Priv. Pass. Autos Only 5 - Owned Autos Subject to No Fault 6 - Owned Autos Subject to a Compulsory UM Law X 7 - Specifically Described Autos 8 - Hired Autos Only 9 - Non -owned Autos Only Policy Effective Date: 0 6 -18 - 2 016 Policy Expiration Date: 0 6 -18 - 2 017 Limits Of $ 1, 000, 000 Combined Single Limit (each accident) Insurance: BI Per Person BI Per Accident PD Per Accident Description of Operations/Locations/Vehicles/Endorsements/Special Provisions THOSE USUAL TO INSURED'S OPERATIONS Interested PartvTvDe: ADDITIONAL INSURED - OTHER THIS CERTIFICATE DOES NOT GRANT ANY COVERAGE OR RIGHTS TO THE CERTIFICATE HOLDER. IF THIS CERTIFICATE INDICATES THAT THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED, THE POLICY(IES) MUST EITHER BE ENDORSED OR CONTAIN SPECIFIC LANGUAGE PROVIDING THE CERTIFICATE H OLDER WITH ADDITIONAL INSURED STATUS. THE CERTIFICATE HOLDER IS AN ADDITIONAL INSURED ONLY TO THE EXTENT INDICATED IN SUCH POLICY LANGUAGE OR ENDORSEMENT. Producer: MARC ST. JULIEN Authorized Representative: Date: 04-18-17 Includes copyrighted material of Insurance Services Office, Inc., with its permission CI CW A021011 Allstate Insurance Company Certificate Copy Page 1 of 1 a Policy Number: Date Entered: 03/29/2017 .4i��DATE (MMIDDIYYYY} CERTIFICATE OF LIABILITY INSURANCE 3/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer ri hts to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Agopian Insurance Services, Inc. NAME; _ _ _ _ _ _ _ 434 W.Broadwa PHONE (818) 545-7517 �a Noy; {618) 548-9699 Y EMAIL lili@agopianinsurance.com Glendale, Ca 91204 A0 RE5.L — — INSUR!NSI AFFORDING COVERAGE _ NAIC 11 _ _ INSURERA,STATE COMPENSATION INSURANCE FUND INSURED MAGIC JUMP RENTALS RIVERSIDE LLC INSURER e; 765 S LUGO AVE SAN BERNANDINOr CA 92408 INSURER C : INSURER D : INSURER E COVERAGES CERTIFICATE NUMBER: REVISION NUMBER_ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES- LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS- INSR 7ypE OF INSURANCE I LTR POLICY NUMBER POLICY YYY POLICY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE [ OCCUR EACH OCCURRENCE I S MED EXP (Any one person) H PERSONAL & ADV INJURY I GENERAL AGGREGATE S GENT AGGREGATE LIMIT APPLIES PER POLICY JE Q �j LOG PRODUCTS - COMPIOP AGG f OTHER: AUTOMOBILE LIABILITY _ COMBINED SINGLE LIMIT Ea acudent BODILY INJURY (Per person) I ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per aaadenq J �a PROPERTY DAMAGE Per accident HIRED NON -OWNED AUTOS ONLY AUTOS ONLY .9 I UMBRELLA LIAR OCCUR EACH OCCURRENCE S ` AGGREGATE EXCESS LIAR CLAIMS -MADE y S j� V DED I RETENTIONS I = i WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I M A �ANY,PROPRIET(�-�PARTNEF?JEXECUTIVE D17FCF-.R.-TiWEMBERUCLUDED7 (Mendatorp In NH} p "s. dasrnhe u'Upr DE SCRIP, ION OF OPERATIONS below NIA' 913811.8—.16 07/21/2016 I07/2I/2017 i '� PER DiF'I• ^s7ATUTE ER _ S 1000000 1 1000000- — $ 1000000 E-L EACH ACC4DENT E.L. DISEASE - EA EMPLLY_EE I i E_L. DISEASE - POLICY 1:.Mlt w DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES [ACORD 101, Additional Remarks Schedule, may be attached IT more space Is required) GtF{ I Il-IGA I t HULL)EK L ANt LLLA I IVn CITY OF LA QUINTA F78495 CALLE TAMPICO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE LA QUINTA CA 92253 THE EXPIRATION DATE THEREOF�, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PWVJSIONS. AUTHORIZED REPRESENTATIVE 15 ACORD CO€ PWTION. All rights reserved- ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Produced uslno Forms Boss Plus software www,FormsBoss corn: Imoressive Publishino 800-208-1977 JULY 22, 2016 MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 Dear Policyholder IN REPLY REFER TO: 9138118-16 Thank you for choosing us as your workers' compensation insurance carrier. This package contains your renewal documents as listed on the following page. Please keep these together. Our goal is to provide you with fast, efficient, and the most convenient service possible. We truly appreciate your business. If you have any questions about the information in this mailing, please contact your broker of record or your local State Compensation Insurance Fund office. State Compensation Insurance Fund BROKER COPY 5880 Owens Dr . Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-8792 IN REPLY REFER TO: 9138118-16 WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY STATE COMPENSATION INSURANCE FUND Forms and Endorsements Applicable List Policy 10963A ANNUAL RATING ENDORSEMENT 10217 1901 -ENDORSEMENT AGREEMENT - LIMITED LIABILITY COMPANY MANAGER(S)-MEMBERS) EXCLUDED 10217 2029 -ENDORSEMENT AGREEMENT- CALIFORNIA SHORT -RATE CANCELATION 10217 2089 -ENDORSEMENT AGREEMENT - STATUTORY ACCOUNTING PRINCIPLES - BILL RECEIVABLE 10217 2437 -ENDORSEMENT AGREEMENT - MEDICAL PROVIDER NETWORK ENDORSEMENT 10217 2559A -ENDORSEMENT AGREEMENT - TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 10217 3017 -ENDORSEMENT AGREEMENT - LIMITED LIABILITY COMPANY MEMBERS - MINIMUM/MAXIMUM LIMITS 10610B POLICY HOLDER NOTICE BROKER COPY 5880 Owens Dr . Pleasanton, CA 94588-3900 Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-8792 HOME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD BE CORRECTED OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL US. IMPORTANT THIS IS NOT A BILL CONTINUOUS POLICY 9138118-16 SEND NO MONEY UNLESS STATEMENT IS ENCLOSED THE RATING PERIOD BEGINS AND ENDS AT 12:01AM RATING PERIOD 7-21-16 TO 7-21-17 PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC DEPOSIT PREMIUM 765 S LUGO AVE MINIMUM PREMIUM SAN BERNARDINO, CALIF 92408 PREMIUM ADJUSTMENT PERIOD NAME OF EMPLOYER- MAGIC JUMP RENTALS RIVERSIDE, LLC CODE NO. PRINCIPAL WORK AND RATES EFFECTIVE FROM 07-21-16 TO 07-21-17 PREMIUM BASE BASIS RATE 8017-1 STORES--RETAIL--N.O.C. 10000 "BUREAU NOTE INFORMATION FEIN 473041079 TOTAL ESTIMATED ANNUAL PREMIUM $994 $863.00 $750.00 QUARTERLY R NA INTERIM BILLING RATE* 9.04 9.94 BROKER COPY COUNTERSIGNED AND ISSUED AT SAN FRANCI�SCO JULY 22, 2016 POLICY L PAGE 1 OF 3 SCIF FORM 10963A (REV.7-2014) OVER PLEASE) HOME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. HERE ARE YOUR NEW RATES FOR THE PERIOD INDICATED. IF YOUR NAME OR ADDRESS SHOULD BE CORRECTED OR IF INSURANCE IS NOT NEEDED FOR NEXT YEAR, PLEASE TELL US. IMPORTANT THIS IS NOT A BILL CONTINUOUS POLICY 9138118-16 SEND NO MONEY UNLESS STATEMENT IS ENCLOSED THE RATING PERIOD BEGINS AND ENDS AT 12:01AM RATING PERIOD 7-21-16 TO 7-21-17 PACIFIC STANDARD TIME INTERIM BILLING RATES WILL BE USED ON PAYROLL REPORTS. THEY TAKE INTO ACCOUNT RATING PLAN CREDITS (OR DEBITS) WHICH WILL APPLY AT FINAL BILLING AND AN ESTIMATE OF YOUR PREMIUM DISCOUNT AS DETAILED BELOW. RATING PLAN CREDITS (DEBITS) EFFECTIVE FROM 07-21-16 TO 07-21-17 RATING PLAN MODIFIER ESTIMATED PREMIUM DISCOUNT MODIFIER 1.10000 1.00000 COMPOSITE FACTOR APPLIED TO BASE RATES TO DERIVE INTERIM BILLING RATES 1.10000 PREMIUM DISCOUNT SCHEDULE EFFECTIVE FROM 07-21-16 TO 07-21-17 ESTIMATED MODIFIED PREMIUM IS DISCOUNTED ACCORDING TO THE FOLLOWING SCHEDULE: FIRST ABOVE $5,000 $5,000 0.0% 11.3% THE ESTIMATED PREMIUM DISCOUNT IS BASED ON AN ESTIMATE OF YOUR PAYROLL. ACTUAL PREMIUM DISCOUNT APPLIED AT FINAL BILLING WILL BE BASED ON THE ACTUAL PAYROLL REPORTED ON YOUR POLICY AND SUBJECT TO AUDIT. BROKER COPY COUNTERSIGNED AND ISSUED AT SAN FRANCI�SCO JULY 22, 2016 POLICY L PAGE 2 OF 3 SCIF FORM 10963A (REV.7-2014) OVER PLEASE) HOME OFFICE SAN FRANCISCO ANNUAL RATING ENDORSEMENT IT IS AGREED THAT THE CLASSIFICATIONS AND RATES PER $100 OF REMUNERATION APPEARING IN THE CONTINUOUS POLICY ISSUED TO THIS EMPLOYER ARE AMENDED AS SHOWN BELOW. CONTINUOUS POLICY 9138118-16 IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR LOCAL STATE FUND OFFICE BELOW: CSC — POLICY AT VACAVILLE 1020 VAQUERO CIRCLE VACAVILLE CA 95688 (877) 405-4545 Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions agreements or limitations of the Policy other than as herein stated. When countersigned by a duly authorized officer or representative of the State Compensation Insurance Fund, these declarations shall be valid and form part of the Policy. AUTHORIZED REPRESENTATIVE PRESIDENT AND CEO COUNTERSIGNED AND ISSUED AT SAN FRANCISCO JULY 22, 2016 SCIF FORM 10963A (REV.7-2014) POLICY L PAGE 3 OF 3 ENDORSEMENT AGREEMENT BROKER COPY HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME LIMITED LIABILITY COMPANY MANAGER(S)-MEMBERS) EXCLUDED EFFECTIVE JULY 21, 2016 AT 12.01 A.M. MAGIC JUMP RENTALS 765 S LUGO AVE SAN BERNARDINO, CA RIVERSIDE, LLC 92408 9138118-16 RENEWAL NA PAGE 1 OF 1 ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. IT IS AGREED THAT, EXCEPT AS OTHERWISE PROVIDED IN THE FOLLOWING PARAGRAPH, THIS POLICY SHALL ACT AS AN ELECTION UNDER CALIFORNIA LABOR CODE SECTION 4151(A) TO INCLUDE ALL MANAGER (S) -MEMBER (S) OF THE LIMITED LIABILITY COMPANY NAMED AS INSURED UNDER THE COMPENSATION PROVISIONS OF DIVISION 4 OF SAID LABOR CODE. IT IS FURTHER AGREED THAT THIS POLICY SHALL NOT OPERATE AS AN ELECTION BY THE INSURED TO COME UNDER THE COMPENSATION PROVISIONS OF DIVISION 4 OF THE LABOR CODE IN RESPECT TO THOSE MANAGER (S) -MEMBER (S) OF THE INSURED WHO ARE SPECIFICALLY NAMED BELOW AND THUS, IT IS AGREED THAT THIS POLICY DOES NOT INSURE THE FOLLOWING NAMED MANAGER(S)- --- --- ------ MEMBER (S) . BAGUMYAN,SARMEN HAKOPIAN,HOVIK IT IS ALSO FURTHER AGREED THAT IN THE EVENT THAT THE STATUS OF THE INSURED LIMITED LIABILITY COMPANY OR THE STATUS OF ANY MANAGER(S)-MEMBER(S) CHANGES AS RESPECTS THE PROVISIONS OF CALIFORNIA LABOR CODE SECTION 3351(F), THE FOREGOING PERTINENT PROVISIONS OF THIS ENDORSEMENT CEASE TO BE EFFECTIVE AND THE INSURING PROVISIONS STATED ELSEWHERE IN THE POLICY SHALL EXTEND. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 1901 OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY CALIFORNIA SHORT -RATE CANCELATION 9138118-16 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ARE TO JULY 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 THE INSURANCE UNDER THIS POLICY IS LIMITED AS FOLLOWS: IT IS AGREED THAT ANYTHING IN THE POLICY TO THE CONTRARY NOTWITHSTANDING, SUCH INSURANCE AS IS AFFORDED BY THIS POLICY IS SUBJECT TO THE FOLLOWING PROVISIONS: IF YOU CANCEL THE POLICY AND A DISCLOSURE WAS PROVIDED IN ACCORDANCE WITH SECTION 481(C) OF THE CALIFORNIA INSURANCE CODE, FINAL PREMIUM WILL BE BASED ON THE TIME THIS POLICY WAS IN FORCE AND INCREASED BY THE SHORT -RATE CANCELATION TABLE BELOW: SHORT -RATE CANCELATION TABLE FINAL PREMIUM BASED ON THE TABLE BELOW WILL NOT BE LESS THAN THE MINIMUM PREMIUM FOR THIS POLICY. DAYS = EXTENDED NUMBER OF DAYS = PERCENTAGE OF FULL POLICY PREMIUM DAYS % DAYS % DAYS ---- 1 - 5% ---- 2 - 6% ---- 3-4 - 7% 5-6 8% 7-8 9% 9-10 10% 11-12 11% 13-14 12% 15-16 13% 17-18 14% 19-20 15% 21-22 16% 23-25 17% 26-29 18% 30-32 19% 33-36 20% 37-40 21% 41-43 22% 44-47 23% 48-51 24% 52-54 25% 55-58 26% 59-62 27% 63-65 28% CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 1 OF 2 2029 OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY CALIFORNIA SHORT -RATE CANCELATION 9138118-16 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ARE TO JULY 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 CONTINUED. 66-69 29% 70-73 30% 74-76 31% 77-80 32% 81-83 33% 84-87 34% 88-91 35% 92-94 36% 95-98 37% 99-102 38% 103-105 39% 106-109 40% 110-113 41% 114-116 42% 117-120 43% 121-124 44% 125-127 45% 128-131 46% 132-135 47% 136-138 48% 139-142 49% 143-146 50% 147-149 51% 150-153 52% 154-156 53% 157-160 54% 161-164 55% 165-167 56% 168-171 57% 172-175 58% 176-178 59% 179-182 60% 183-187 61% 188-191 62% 192-196 63% 197-200 64% 201-205 65% 206-209 66% 210-214 67% 215-218 68% 219-223 69% 224-228 70% 229-232 71% 233-237 72% 238-241 73% 242-246 74% 247-250 75% 251-255 76% 256-260 77% 261-264 78% 265-269 79% 270-273 80% 274-278 81% 279-282 82% 283-287 83% 288-291 84% 292-296 85% 297-301 86% 302-305 87% 306-310 88% 311-314 89% 315-319 90% 320-323 91% 324-328 92% 329-332 93% 333-337 94% 338-342 95% 343-346 96% 347-351 97% 352-355 98% 356-360 99% 361-365 100% NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 2 OF 2 2029 OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME STATUTORY ACCOUNTING PRINCIPLES BILL RECEIVABLE EFFECTIVE JULY 21, 2016 AT 12.01 A.M. MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 9138118-16 RENEWAL NA PAGE 1 OF 1 ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. IT IS AGREED THAT THIS ENDORSEMENT AMENDS SECTION D. OF PART FIVE OF THE POLICY. YOUR POLICY HAS BEEN WRITTEN ON QUARTERLY ADJUSTMENT PERIOD. YOU WILL PAY ALL PREMIUM WHEN DUE. PAYROLL REPORTS AND PREMIUM ARE DUE WITHIN 10 DAYS (TEN) AFTER THE LAST DAY OF THE REPORTING PERIOD. PAYMENT OF OUTSTANDING PREMIUM IS DUE WITHIN 10 DAYS (TEN) FROM THE BILL DATE. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 2089 OLD DP 217 ENDORSEMENT AGREEMENT MEDICAL PROVIDER NETWORK BROKER COPY HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE JULY 21, 2016 AT 12.01 A.M. MAGIC JUMP RENTALS 765 S LUGO AVE SAN BERNARDINO, CA RIVERSIDE, LLC 92408 9138118-16 RENEWAL NA PAGE 1 OF 3 ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. THE STATE COMPENSATION INSURANCE FUND MEDICAL PROVIDER NETWORK IS ESTABLISHED IN ACCORDANCE WITH CALIFORNIA LABOR CODE 4600 ET SEQ AND APPROVED BY THE CALIFORNIA DIVISION OF WORKERS' COMPENSATION ADMINISTRATIVE DIRECTOR. THE INTENT OF THE 2004 LEGISLATION REQUIRING THE ESTABLISHMENT OF THE MEDICAL PROVIDER NETWORK IS INCREASED EMPLOYER CONTROL OVER THE COSTS OF TREATING EMPLOYEE WORK RELATED INJURIES AND DISEASE. PART FOUR OF THE POLICY, YOUR DUTIES IF INJURY OCCURS, IS AMENDED AS FOLLOWS: IT IS AGREED THAT THE POLICYHOLDER SHALL REFER ALL WORK RELATED INJURIES OR DISEASE TO THE STATE COMPENSATION INSURANCE FUND MEDICAL PROVIDER NETWORK AT THE TIME OF AN OCCUPATIONAL INJURY OR UPON KNOWLEDGE OF AN OCCUPATIONAL INJURY OR DISEASE. IT IS FURTHER AGREED THAT WHEN AN EMPLOYEE NOTIFIES THE POLICYHOLDER OF AN OCCUPATIONAL INJURY OR FILES A CLAIM FOR WORKERS' COMPENSATION WITH THE POLICYHOLDER, THE POLICY- HOLDER SHALL ARRANGE AN INITIAL MEDICAL EVALUATION AND BEGIN TREATMENT WITHIN THE MEDICAL PROVIDER NETWORK. THE POLICYHOLDER SHALL NOTIFY THE EMPLOYEE OF HIS OR HER RIGHT CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 2437 OLD DP 217 ENDORSEMENT AGREEMENT MEDICAL PROVIDER NETWORK BROKER COPY HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME EFFECTIVE JULY 21, 2016 AT 12.01 A.M. MAGIC JUMP RENTALS 765 S LUGO AVE SAN BERNARDINO, CA CONTINUED. RIVERSIDE, LLC 92408 9138118-16 RENEWAL NA PAGE 2 OF 3 TO BE TREATED BY A PHYSICIAN OF HIS OR HER CHOICE FROM WITHIN THE MEDICAL PROVIDER NETWORK AFTER THE FIRST VISIT. THE POLICYHOLDER SHALL NOTIFY EMPLOYEE OF THE METHOD BY WHICH THE LIST OF PARTICIPATING PROVIDERS MAY BE ACCESSED BY EMPLOYEES. IT IS FURTHER AGREED THAT IF AN INJURED EMPLOYEE DISPUTES EITHER THE DIAGNOSIS OR THE TREATMENT PRESCRIBED BY THE TREATING PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF ANOTHER PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IF THE INJURED EMPLOYEE DISPUTES THE DIAGNOSIS OR TREATMENT PRESCRIBED BY THE SECOND PHYSICIAN, THE EMPLOYEE MAY SEEK THE OPINION OF A THIRD PHYSICIAN WITHIN THE MEDICAL PROVIDER NETWORK. IT IS FURTHER AGREED THAT THIS ENDORSEMENT IN NO WAY AFFECTS THE RIGHTS OF AN INJURED WORKER TO PREDESIGNATE A PHYSICIAN. AN EMPLOYEE MUST FILE WRITTEN NOTICE OF THE PREDESIGNATION WITH THE EMPLOYER PRIOR TO THE DATE OF INJURY. THE NOTICE MUST INCLUDE THE PHYSICIAN'S SIGNATURE OF AGREEMENT TO THE PREDESIGNATION, AND THE FOLLOWING CONDITIONS MUST APPLY: THE PHYSICIAN IS THE EMPLOYEE'S REGULAR PHYSICIAN. THE PHYSICIAN IS THE EMPLOYEE'S PRIMARY CARE PROVIDER WHO HAS PREVIOUSLY DIRECTED THE MEDICAL TREATMENT OF THE CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 2437 PRESIDENT AND CEO OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY MEDICAL PROVIDER NETWORK HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 CONTINUED. 9138118-16 RENEWAL NA PAGE 3 OF 3 EMPLOYEE AND RETAINS RECORDS OF THE TREATMENT AND MEDICAL HISTORY. THE EMPLOYER PROVIDES THE STAFF WITH NONOCCUPATIONAL GROUP HEALTH COVERAGE IN A HEALTH-CARE SERVICE PLAN (SUCH AS AN HMO/PPO PROGRAM). OR THE EMPLOYER PROVIDES NONOCCUPATIONAL HEALTH COVERAGE IN A GROUP HEALTH PLAN OR A GROUP HEALTH INSURANCE POLICY, PER LABOR CODE 4616.7. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 2437 OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 9138118-16 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ARE TO JULY 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 THIS ENDORSEMENT ADDRESSES THE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT OF 2002 AS AMENDED AND EXTENDED BY THE TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015. IT SERVES TO NOTIFY YOU OF CERTAIN LIMITATIONS UNDER THE ACT, AND THAT YOUR INSURANCE CARRIER IS CHARGING PREMIUM FOR LOSSES THAT MAY OCCUR IN THE EVENT OF AN ACT OF TERRORISM. YOUR POLICY PROVIDES COVERAGE FOR WORKERS COMPENSATION LOSSES CAUSED BY ACTS OF TERRORISM, INCLUDING WORKERS COMPENSATION BENEFIT OBLIGATIONS DICTATED BY STATE LAW. COVERAGE FOR SUCH LOSSES IS STILL SUBJECT TO ALL TERMS, DEFINITIONS, EXCLUSIONS, AND CONDITIONS IN YOUR POLICY, AND ANY APPLICABLE FEDERAL AND/OR STATE LAWS, RULES, OR REGULATIONS. DEFINITIONS THE DEFINITIONS PROVIDED IN THIS ENDORSEMENT ARE BASED ON AND HAVE THE SAME MEANING AS THE DEFINITIONS IN THE ACT. IF WORDS OR PHRASES NOT DEFINED IN THIS ENDORSEMENT ARE DEFINED IN THE ACT, THE DEFINITIONS IN THE ACT WILL APPLY. "ACT" MEANS THE TERRORISM RISK INSURANCE ACT OF 2002, WHICH TOOK EFFECT ON NOVEMBER 26, 2002, AND ANY AMENDMENTS THERETO, INCLUDING ANY AMENDMENTS RESULTING FROM THE TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 1 OF 5 2559A OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 9138118-16 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ARE TO JULY 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 CONTINUED. "ACT OF TERRORISM" MEANS ANY ACT THAT IS CERTIFIED BY THE SECRETARY OF THE TREASURY, IN CONSULTATION WITH THE SECRETARY OF HOMELAND SECURITY, AND THE ATTORNEY GENERAL OF THE UNITED STATES AS MEETING ALL OF THE FOLLOWING REQUIREMENTS: A. THE ACT IS AN ACT OF TERRORISM. B. THE ACT IS VIOLENT OR DANGEROUS TO HUMAN LIFE, PROPERTY OR INFRASTRUCTURE. C. THE ACT RESULTED IN DAMAGE WITHIN THE UNITED STATES, OR OUTSIDE OF THE UNITED STATES IN THE CASE OF THE PREMISES OF UNITED STATES MISSIONS OR CERTAIN AIR CARRIERS OR VESSELS. D. THE ACT HAS BEEN COMMITTED BY AN INDIVIDUAL OR INDIVIDUALS AS PART OF AN EFFORT TO COERCE THE CIVILIAN POPULATION OF THE UNITED STATES OR TO INFLUENCE THE POLICY OR AFFECT THE CONDUCT OF THE UNITED STATES GOVERNMENT BY COERCION. "INSURED LOSS" MEANS ANY LOSS RESULTING FROM AN ACT OF TERRORISM (AND, EXCEPT FOR PENNSYLVANIA, INCLUDING AN ACT OF WAR, IN THE CASE OF WORKERS COMPENSATION) THAT IS COVERED BY PRIMARY OR EXCESS PROPERTY AND CASUALTY INSURANCE ISSUED BY AN INSURER IF THE LOSS OCCURS IN THE UNITED STATES OR AT THE PREMISES OF UNITED STATES MISSIONS OR TO CERTAIN AIR CARRIERS OR VESSELS. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 2 OF 5 2559A OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 9138118-16 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ARE TO JULY 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 CONTINUED. "INSURER DEDUCTIBLE" MEANS, FOR THE PERIOD BEGINNING ON JANUARY 1, 2015, AND ENDING ON DECEMBER 31, 2020, AN AMOUNT EQUAL TO 20% OF OUR DIRECT EARNED PREMIUMS, DURING THE IMMEDIATELY PRECEDING CALENDAR YEAR. LIMITATION OF LIABILITY THE ACT LIMITS OUR LIABILITY TO YOU UNDER THIS POLICY. IF AGGREGATE INSURED LOSSES EXCEED $100,000,000,000 IN A CALENDAR YEAR AND IF WE HAVE MET OUR INSURER DEDUCTIBLE, WE ARE NOT LIABLE FOR THE PAYMENT OF ANY PORTION OF THE AMOUNT OF INSURED LOSSES THAT EXCEEDS $100,000,000,000; AND FOR AGGREGATE INSURED LOSSES UP TO $100,000,000,000, WE WILL PAY ONLY A PRO RATA SHARE OF SUCH INSURED LOSSES AS DETERMINED BY THE SECRETARY OF THE TREASURY. POLICYHOLDER DISCLOSURE NOTICE 1. INSURED LOSSES WOULD BE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT. IF THE AGGREGATE INDUSTRY INSURED LOSSES EXCEED: A. $100,000,000, WITH RESPECT TO SUCH INSURED LOSSES OCCURRING IN CALENDAR YEAR 2015, THE UNITED STATES GOVERNMENT WOULD PAY 85% OF OUR INSURED LOSSES THAT EXCEED OUR INSURER DEDUCTIBLE. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 3 OF 5 2559A OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 9138118-16 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ARE TO JULY 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 CONTINUED. B. $120,000,000, WITH RESPECT TO SUCH INSURED LOSSES OCCURRING IN CALENDAR YEAR 2016, THE UNITED STATES GOVERNMENT WOULD PAY 84% OF OUR INSURED LOSSES THAT EXCEED OUR INSURER DEDUCTIBLE. C. $140,000,000, WITH RESPECT TO SUCH INSURED LOSSES OCCURRING IN CALENDAR YEAR 2017, THE UNITED STATES GOVERNMENT WOULD PAY 83% OF OUR INSURED LOSSES THAT EXCEED OUR INSURER DEDUCTIBLE. D. $160,000,000, WITH RESPECT TO SUCH INSURED LOSSES OCCURRING IN CALENDAR YEAR 2018, THE UNITED STATES GOVERNMENT WOULD PAY 82% OF OUR INSURED LOSSES THAT EXCEED OUR INSURER DEDUCTIBLE. E. $180,000,000, WITH RESPECT TO SUCH INSURED LOSSES OCCURRING IN CALENDAR YEAR 2019, THE UNITED STATES GOVERNMENT WOULD PAY 81% OF OUR INSURED LOSSES THAT EXCEED OUR INSURER DEDUCTIBLE. F. $200,000,000, WITH RESPECT TO SUCH INSURED LOSSES OCCURRING IN CALENDAR YEAR 2020, THE UNITED STATES GOVERNMENT WOULD PAY 80% OF OUR INSURED LOSSES THAT EXCEED OUR INSURER DEDUCTIBLE. CONTINUED NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 4 OF 5 2559A OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 9138118-16 RENEWAL NA HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 21, 2016 AT 12.01 A.M. PAGE ALL EFFECTIVE DATES ARE TO JULY 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 CONTINUED. 2. NOTWITHSTANDING ITEM 1 ABOVE, THE UNITED STATES GOVERNMENT WILL NOT MAKE ANY PAYMENT UNDER THE ACT FOR ANY PORTION OF INSURED LOSSES THAT EXCEED $100,000,000,000. 3. THE PREMIUM CHARGE FOR THE COVERAGE YOUR POLICY PROVIDES FOR INSURED LOSSES IS INCLUDED IN THE AMOUNT SHOWN IN ITEM 4 OF THE INFORMATION PAGE OR IN THE SCHEDULE BELOW. THIS ENDORSEMENT CHANGES THE POLICY TO WHICH IT IS ATTACHED AND IS EFFECTIVE ON THE DATE ISSUED UNLESS OTHERWISE STATED. WC 00 04 22 B NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 5 OF 5 2559A OLD DP 217 ENDORSEMENT AGREEMENT BROKER COPY HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME LIMITED LIABILITY COMPANY MEMBERS MINIMUM MAXIMUM LIMITS EFFECTIVE JULY 21, 2016 AT 12.01 A.M. MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 9138118-16 RENEWAL NA PAGE 1 OF 1 ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT. IT IS AGREED THAT UNLESS OTHERWISE EXCLUDED BY ENDORSEMENT THE ACTUAL REMUNERATION EARNED BY EACH MEMBER DURING THE POLICY PERIOD SHALL BE USED AS THE BASIS OF PREMIUM, SUBJECT TO THE MINIMUM AMOUNT OF $ 45,500 PER ANNUM AND THE MAXIMUM AMOUNT OF $ 117,000 PER ANNUM AS SPECIFIED IN THE CALIFORNIA WORKERS' COMPENSATION UNIFORM STATISTICAL REPORTING PLAN, FOR WORKERS' COMPENSATION INSURANCE IN EFFECT DURING THE POLICY PERIOD. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) JULY 22, 2016 PRESIDENT AND CEO 3017 OLD DP 217 9138118-16 Dear Policyholder: These endorsements amend and are part of your policy. Please keep them with your documents for future reference. If you have any questions concerning these endorsements, Please contact your local State Fund office. BROKER COPY POLICYHOLDER NOTICE Page 1 of S YOUR RIGHT TO RATING AND DIVIDEND INFORMATION PN 04 99 01 F (Ed. 03-15) POLICY NO. 9138118-16 NR NA MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CALIF 92408 Information Available to You. A. Information Available from Us - State Compensation Insurance Fund (1) General questions regarding your policy should be directed to: State Fund, Customer Service Center 1020 Vaquero Circle Vacaville, CA 95688 Telephone: 888-782-8338 (2) Dividend Calculation. If this is a participating policy (a policy on which a dividend may be paid), upon payment or non-payment of a dividend, we shall provide a written explanation to you that sets forth the basis of the dividend calculation. The explanation will be in clear, understandable language and will express the dividend as a dollar amount and as a percentage of the earned premium for the policy year on which the dividend is calculated. (3) Claims Information. Pursuant to Sections 3761 and 3762 of the California Labor Code, you are entitled to receive information in our claim files that affects your premium. Copies of documents will be supplied at your expense during reasonable business hours. For claims covered under this policy, we will estimate the ultimate cost of unsettled claims for statistical purposes eighteen months after the policy becomes effective and will report those estimates to the Workers' Compensation Insurance Rating Bureau of California (WCIRB) no later than twenty months after the policy becomes effective. The cost of any settled claims will also be reported at that time. At twelve-month intervals thereafter, we will update and report to the WCIRB the estimated cost of any unsettled claims and the actual final cost of any claims settled in the interim.The amounts we report will be used by the WCIRB to compute your experience modification if you are eligible for experience rating. B. Information Available from the Workers' Compensation Insurance Rating Bureau of California (1) The WCIRB is a licensed rating organization and the California Insurance Commissioner's designated statistical agent. As such, the WCIRB is responsible for administering the California Workers' Compensation Uniform Statistical Reporting Plan--1995 (USRP) and the California Workers' Compensation Experience Rating Plan--1995(ERP). Contact information for the WCIRB is: WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Customer Service. You may also contact WCIRB Customer Service at 1-888-229-2472, by fax at 415-778-7272, or via the Internet at the WCIRB's website: http://www.wcirb.com. The regulations contained in the USRP and the ERP are available for public viewing through the WCIRB's website. (2) Policyholder Information. Pursuant to California Insurance Code (CIC) Section 11752.6, upon written request, you are entitled to information relating to loss experience, claims, classification assignments, and policy contracts as well as rating plans, rating systems, manual rules, or other information impacting your premium that is maintained in the records of the WCIRB. Complaints and Requests for Action requesting policyholder information should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Custodian of Records. The Custodian of Records can be reached by telephone at 415-777-0777 and by fax at 415-778-7272. 01 a = � 0-610ID SC IF 10610 B (Rev. 04-15) Page 2 of 3 POLICYHOLDER NOTICE Your Right to Rating and Dividend Information POLICY NO. 9138118-16 NR NA (3) Experience Rating Form. Each experience rated risk may receive a single copy of its current Experience Rating Form free of charge by completing a Policyholder Rate Sheet Request Form on the WCIRB's website at http://wcirb.com/ratesheet. The Experience Rating Form will include a Loss -Free Rating, which is the experience modification that would have been calculated if $0 (zero) actual losses were incurred during the experience period. This hypothetical rating calculation is provided for informational purposes only. II. Dispute Process You may dispute our actions or the actions of the WCIRB pursuant to CIC Sections 11737 and 11753.1. A. Our Dispute Resolution Process. You may request in writing that we reconsider a change in a classification assignment that results in an increased premium. You may also request, in writing, that we review the manner in which our rating system has been applied in connection with the insurance afforded or offered you. Written requests that we reconsider or review our actions should be forwarded to: State Compensation Insurance Fund, Attention: Manager, Customer Assistance Program, 5880 Owens Drive, Pleasanton, CA 94588 or call us at 925-460-6530 or fax us at 925-460-6633. B. Disputing the Actions of the WCIRB. If you have been aggrieved by any decision, action, or omission to act of the WCIRB, you may request, in writing, that the WCIRB reconsider its decision, action, or omission to act. You may also request, in writing, that the WCIRB review the manner in which its rating system has been applied in connection with the insurance afforded or offered you. For requests related to classification disputes, the reporting of experience, or coverage issues, your initial request for review must be received by the WCIRB within 12 months after the expiration date of the policy to which the request for review pertains, except if the request involves the application of the Revision of Losses rule. For requests related to your experience modificaton, your initial request for review must be received by the WCIRB within 6 months after the issuance, or 12 months after the expiration date, of the experience modification to which the request for review pertains, whichever is later, except if the request for review involves the application of the Revision of Losses rule. If the request involves the Revision of Losses rule, the time to state your appeal may be longer. (See Section VI, Rule 14 of the ERP). You may commence the review process by sending the WCIRB a written Inquiry. Written Inquiries should be sent to: WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Customer Service. Customer Service can be reached by telephone at 1-888-229-2472, and by fax at 415-778-7272. If you are dissatisfied with the WCIRB's decision upon an Inquiry, or if the WCIRB fails to respond within 90 days after receipt of the Inquiry, you may pursue the subject of the Inquiry by sending the WCIRB a written Complaint and Request for Action. After you send your Complaint and Request for Action, the WCIRB has 30 days to send you written notice indicating whether or not your written request will be reviewed. If the WCIRB agrees to review your request, it must conduct the review and issue a decision granting or rejecting your request within 60 days after sending you the written notice granting review. If the WCIRB declines to review your request, if you are dissatisfied with the decision upon review, or if the WCIRB fails to grant or reject your request or issue a decision upon review, you may appeal to the insurance commissioner as described in paragraph II.C., below. Written Complaints and Requests for Action should be forwarded to: WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Complaints and Reconsiderations. The WCIRB's telephone number is 1-888-229-2472, and the fax number is 415-371-5204. SC IF 10610 B (Rev. 04-15) Page 3 of 3 POLICYHOLDER NOTICE Your Right to Rating and Dividend Information POLICY NO. 9138118-16 NR NA C. California Department of Insurance - Appeals to the Insurance Commissioner. If, after you follow the appropriate dispute resolution process described above, we or the WCIRB decline to review your request, if you are dissatisfied with the decision upon review, or if we or the WCIRB fail to grant or reject your request or issue a decision upon review, you may appeal to the insurance commissioner pursuant to CIC Sections 11737, 11752.6, 11753.1 and Title 10, California Code of Regulations, Section 2509.40 et seq. You must file your appeal within 30 days after we or the WCIRB send you the notice rejecting review of your request for reconsideration or the decision upon your request for reconsideration. If no written decision regarding your request is sent, your appeal must be filed within 120 days after you sent your request for reconsideration to us or to the WCIRB. The filing address for all appeals to the insurance commissioner is: Administrative Hearing Bureau California Department of Insurance 45 Fremont Street, 22nd Floor San Francisco, California 94105 You have the right to a hearing before the insurance commissioner, and our action, or the action of the WCIRB, may be affirmed, modified, or reversed. III. Resources Available to You in Obtaining Information and Pursuing Disputes A. Policyholder Ombudsman. Pursuant to California Insurance Code Section 11752.6, a policyholder ombudsman is available at the WCIRB to assist you in obtaining and evaluating the rating, policy, and claims information referenced in I.A. and I. B., above. The ombudsman may advise you on any dispute with us, the WCIRB, or on an appeal to the insurance commissioner pursuant to Section 11737 of the Insurance Code. The address of the policyholder ombudsman is WCIRB, 1221 Broadway, Suite 900, Oakland, California 94612, Attention: Policyholder Ombudsman. The policyholder ombudsman can be reached by telephone at 415-778-7159 and by fax at 415-371-5288. B. California Department of Insurance - Information and Assistance. Information and assistance on policy questions can be obtained from the Department of Insurance Consumer HOTLINE, 1-800-927- HELP (4357) or http://www.insurance.ca.gov. For questions and correspondence regarding appeals to the Administrative Hearing Bureau, see the contact information in paragraph II.C. This notice does not change the policy to which it is attached. SC IF 10610 B (Rev. 04-15) ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION BROKER COPY HOME OFFICE SAN FRANCISCO ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME 9138118-16 RENEWAL NA PAGE EFFECTIVE APRIL 6, 2017 AT 12.01 A.M. AND EXPIRING JULY 21, 2017 AT 12.01 A.M. MAGIC JUMP RENTALS RIVERSIDE, LLC 765 S LUGO AVE SAN BERNARDINO, CA 92408 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF LA QUINTA WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, MAGIC JUMP RENTALS RIVERSIDE, LLC IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRESENT IVE SCIF FORM 10217 (REV.7-2014) APRIL 11, 2017 PRESIDENT AND CEO 1 OF 1 2570 OLD DP 217 BROKER COPY 913 8118-16 RENEWAL NA PLEASE KEEP THIS ENDORSEMENT WITH YOUR POLICY Dear Policyholder: These endorsements amend and are part of your policy. Please keep them with your documents for future reference. If you have any questions concerning these endorsements, Please contact your local State Fund office.